Nursing - Theses
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ItemA study of the clinical supervision implementation strategy for nurses at a rural health care organisation in Victoria(University of Melbourne, 2006)
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ItemBecoming a Nurse: A mixed Methods Study of Student Nurse Employment and Graduate Nurse Experience( 2023-11)Background: Evaluations have demonstrated that employing student registered nurses (RNs) in healthcare roles may improve their clinical skills and confidence and subsequently, the work readiness of new graduate RNs. The recent expansion of student employment models in healthcare, including the Registered Undergraduate Student of Nursing (RUSON) employment model in Victorian public hospitals, has provided an opportunity to explore the influence of student RN employment on graduate nurse transition to practice. Aim: To explore the ways in which student employment impacts student learning and preparation for practice, and investigate how employment influences transition experience. Research questions: 1. How do different models of student employment influence RN transition to practice? 2. What influence do student employment models have on nursing workforce recruitment and retention? Design/Method: A mixed methods study using a sequential explanatory research design was undertaken in two phases of the study. Phase 1: A cross-sectional survey combining an adapted version of the Revised Casey Fink Graduate Nurse Experience (r-CFGNE) survey tool including additional questions related to student nurse employment and the influence of that employment on learning and preparation. Phase 2: Focus groups/interviews, informed by early review of Phase 1 data, included graduate RNs recruited through the survey. Setting: Public and private hospital system in Victoria, Australia. Participants: RNs currently undertaking a graduate nurse program in Victoria, Australia (June to September 2022). Results: Phase 1: Seven hundred and seventeen participants opened and completed at least some of the survey. Five hundred and thirty-four surveys (74%) completed surveys were included in the analysis. Sixty-five percent of participants worked while they were studying for their nursing degree. Participants indicated that employment in a nursing related role while a student RN influenced their learning: employment in health or aged care 76.3% (p-value < 0.001); employment as a RUSON 75.4%, (p-value <0.001). Similarly, preparation for work was reported to enhanced by employment healthcare roles: employment in health or aged care 77.7% (p- value < 0.001), employment as a RUSON 81.8%, (p-value <0.001). Employment as a RUSON was the role most frequently nominated as having the greatest influence (42.5%), the next most frequent was employment as an AiN/HAN/PCA (21.5%). Differences were observed between type of employment undertaken while studying for a degree in nursing and graduate retention. A significantly larger proportion of nurses who had been employed as a RUSON during the course of their degree indicated that they remained with that employer throughout their graduate year; when compared to other survey participants working in health and aged care (55% vs 23.5% p-value <0.001). In relation to retention, while a greater proportion of RUSONs (68.1%) reported intending to stay in nursing compared to those who did not work in health (63.6%) this difference was not significant (p-value = 0.362). Phase 2: Eighteen nurses who completed the survey participated in an interview or a focus group. Analysis of the qualitative data yielded four themes. Thematic analysis demonstrated that employment in health while undertaking a nursing degree had a positive influence on graduate nurse preparation. Students who were employed in positions that worked directly with an RN were also able to develop a greater connection to nursing. Conclusion: Graduate nurse transition is influenced by engagement in the paid employment as a student. This influence is perceived to be most beneficial where employment provides the student with the opportunity to work in clinical areas with more direct care and nursing experience, particularly when the employment is part of a nursing team. This provides the student with informal but important work integrated learning that could be better utilised. The increased connection to nursing and the workplace may also serve to increase opportunities for graduate nurse recruitment and retention. Implications for nursing: Nursing and midwifery continue to be challenged by workforce pressures, including the recruitment and retention of graduate nurses. This research found that the RUSON model can strengthen the graduate nurse experience and support workforce development. The influence of different student RN employment models on the graduate RN workforce requires further exploration. Further research scoping the models over a longer period of time is required to measure the impact on graduate nurse preparedness for work, practice based learning, and graduate nurse recruitment and retention.
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ItemExploring post-treatment care for women with high-intermediate and high-risk endometrial cancer: A mixed methods study( 2022)Endometrial cancer (EC) imposes a significant burden on women and the health system. Intense post-treatment follow-up (FU) for women with high-intermediate (H-I) and high-risk (H-R) disease lasts five years or longer with only 20% likely to develop recurrence. Death from pre-existing conditions is more likely than from EC. No evidence supports FU improving long-term survival or quality of life. Alternative FU needs consideration. The aim of this thesis was to explore current post-treatment FU models for women with H-I and H-R EC to: - Understand the current model of patient care in addressing survivorship issues. - Identify deficiencies in post-treatment care. - Make recommendations that support optimal care based on women's perspectives and needs. A sequential explanatory mixed methods study was conducted in two phases to: examine patterns of care and disease outcomes; explore the extent to which the current model of care 1) meets women’s physical and emotional needs; 2) addresses survivorship issues. Phase 1: A retrospective case audit was conducted of women referred for adjuvant radiation treatment between 2004 and 2014 who subsequently recurred. Data were analysed using descriptive statistics. Phase 2 recruited women without evidence of disease, attending medically-led FU. Purposive sampling targeted a range of experiences post-treatment. Semi-structured interviews were analysed using inductive thematic approach. Quantitative data results revealed of 786 women referred, 19% developed recurrence. Most (63%) had at least two pre-existing comorbidities. Few notes (9%) documented lifestyle discussions. A third (31%) experienced mild/moderate treatment-related side-effects. Most notes (84%) contained no references to emotional status; few (12%) contained exercise recommendations; few (17%) for those working pre-treatment indicated return to work discussions; seven documented nursing consultation. Most recurrence (87%) occurred within three years post-surgery, 70% was symptomatic. Although treating clinicians detected 59% of recurrences, only 46% were during scheduled FU. The majority (59%) had multi-focal recurrence and poor outcomes. Two years post-treatment for recurrence, 31% were alive, 15% without evidence of disease. Eleven survived four years. Analysis of 25 interviews yielded four themes: ‘The safe haven of FU’; ‘Fear of cancer recurrence’ (FOR); ‘It is more than absence of cancer’; ‘Attitudes and relationships to health care professionals’. Women reported little preparation for survivorship. FU focused on physical symptoms; recurrence detection; treatment toxicity. Attending FU both escalated and alleviated FOR. Generally emotional needs were unmet. Health promotion and practical support toward making lifestyle changes was absent. Women valued specialist-led FU and ongoing connection with them. Women perceived limited contact with nurses in FU. Nurse-led care could provide for unmet needs, including emotional and healthy lifestyle support. In conclusion, this thesis indicates the current model is effective in dealing with medical issues from a disease perspective but is inefficient. In 70% of cases recurrence detection was from symptomatic disease rather than FU. For many, the current model is burdensome and does not comprehensively address survivorship issues. Findings indicate revision of national EC FU guidelines, and reforming EC survivorship care models as needed. Shifting the focus of FU towards addressing women’s post-treatment experiences is overdue. Specialist nurse-led FU should be considered.
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ItemAn exploration of the nursing role in a telehealth based stroke secondary prevention program( 2017)This research study set out to explore a specialist nursing role in the field of Telehealth for chronic disease management. This study aimed to explore the role of the nurse through measurement of nursing activity during the one-year period of participant follow-up. The study aimed to effect long-term secondary prevention of stroke through an evidence based approach to the management of modifiable cardiovascular risk factors and post stroke depression in the community setting. Research suggests that up to 80% reduction of risk of successive stroke can be achieved if recommendations from evidence-based guidelines are implemented. Notwithstanding these findings a gap exists in the implementation of preventative strategies for stroke survivors in the community. Results from previous research indicate that Telehealth is cost effective and potentially may significantly reduce socioeconomic burden and the probability of successive stroke. A small number of studies have highlighted potential mechanisms through which Telehealth can benefit the stroke survivor, carers, families and health professionals. Researchers have recommended more research into Telehealth in order to develop and to define effective interventions. A pilot randomised controlled trial (RCT) conducted at two metropolitan hospitals showed positive results in risk factor and depression outcomes. Integral to this model of care was the role of the nurse. In the current nurse-led, nested multicentre RCT, study nurses gained increased telephone access, to follow-up and support stroke survivors and their General Practitioners. There were 93 participants (43 intervention) recruited from four metropolitan hospitals over a period of two years. Nursing staff were integrated with the multidisciplinary team in designated stroke centres and General Practitioners in the community. Specialists were available to participate in shared care. Telephone follow-up was initially attenuated by risk for second stroke, with high-risk individuals receiving a greater frequency of follow-up. The results indicated that nurses engaged in both fundamental nursing process and advanced activities to assist stroke survivors through transitions across the health landscape after stroke. Case management, assessment and care planning were frequent fundamental activities and occupied a relatively large percentage of the nurse’s time. The mean difference in outcome systolic blood pressure was significantly improved in the intervention group. The mean difference in post stroke depression screening score was significantly better for the intervention group. Lifestyle modification in particular physical activity was better in the intervention group. The results add support to the place of nursing in the ongoing care of stroke survivors in the community setting.
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ItemHow do patients with lung cancer experience radiation induced oesophagitis?( 2016)Patients with lung cancer who receive radiotherapy to their chest may experience the specific treatment toxicity of radiation induced oesophagitis (RIO) if the oesophagus is included in the radiotherapy treatment field. RIO causes significant pain and distress to patients. There is a lack of evidence to guide appropriate management. There is also a lack of information on how patients experience this toxicity. This qualitative, exploratory study examined the experience of RIO described by patients with lung cancer who received RT to the chest, either alone or in combination with chemotherapy. The aims of this project were to: • identify the properties and characteristics of RIO as experienced by the patient having radiotherapy to the chest for lung cancer, • understand how these properties and characteristics change over time, • understand the patient experience of ongoing symptoms following completion of radiotherapy, • identify aspects of the RIO experience amenable to nursing interventions that will assist in the management of RIO and, • establish research questions to test specific nursing interventions for RIO. The Theory of Unpleasant Symptoms (TOUS) was chosen as the conceptual framework for the development of the semi-structured interviews and analysis. Two cohorts of patients were recruited to address the research questions used in this study. Cohort 1 consisted of patients who were actively receiving cancer treatment and experiencing RIO. This cohort provided insight into the experience of RIO in the acute setting, including onset and progression. Cohort 2 consisted of patients who completed treatment for primary lung cancer within the last six months and who experienced Grade 3 RIO at some stage during their treatment. Cohort 2 provided insight into the recovery trajectory following RIO, including long term changes. Semi-structured patient interviews were used to capture the patients experience and recovery of RIO. The interviews sought to identify the properties and characteristics of the pain and swallowing difficulties as described by all patients as well as other relevant features of the experience. Content analysis was used to analyse interview data. Four patient stories were chosen from the interviews to illustrate the overall experience of RIO and recovery as a means of providing context to the findings of this study. These vignettes illustrate the increasing impact on daily life as the severity of RIO increased. The extracted statements identified from the interviews were organised into the four central predetermined categories to describe the experience of RIO: (1) pain, (2) swallowing, (3) management and (4) the impact or bother of the experience of RIO. TOUS provided a framework to capture the symptom dimensions of quality, intensity, duration and associated distress of RIO for each of these categories as experienced by the patients. The patient statements extracted from the interviews were organised into four categories to describe the experience of recovery from Grade 3 RIO. The four categories were (1) memory of pain and swallowing difficulties, (2) time to recovery, (3) long term effects on swallowing and (4) advice for future patients. New knowledge of RIO gained from this study shows that experience changes across the trajectory of RIO, that pain and swallowing are inter-related and require combined therapeutic approaches and that while healing occurs, some swallowing difficulty can persist for some patients.
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ItemFamily function and congenital heart disease( 2013)Introduction: Congenital heart disease (CHD) is one of the most common birth defects, and the most complex defects often require cardiac surgery in early infancy. Cardiac surgery typically requires intensive care unit admission. The ongoing effect on the family from having a baby with CHD that requires surgery in early infancy has been incompletely defined. Aim: To describe family function and the burden of having an infant with operated CHD, in the families of two year-olds who underwent surgery for CHD in early infancy. Method: The primary caregivers (n = 99) of young infants (less than 8 weeks of age) that required cardiac surgery in Melbourne, Australia and Auckland, New Zealand completed a series of psychosocial questionnaires assessing family function, family burden, significant life stress, and coping style when their child with CHD was 2 years old. Initial surgery complexity (RACHS-1), need for reoperation, maternal education, timing of diagnosis, and intensive care length of stay was also collected. Results: Healthy family function was found in the majority (79%), Unhealthy family function related to significant life stress (p < 0.02) and avoidance coping style (p < 0.02). Unhealthy family function did not relate to complexity of surgery, diagnostic class, need for reoperation, intensive care length of stay, or maternal education. There was a greater family burden for those with more complex lesions (single ventricle physiology with initial palliation) compared to less complex lesions (biventricular physiology requiring corrective surgery) (p < .02). Conclusion: The majority of families of two year-olds with operated CHD had healthy family function. Unhealthy family function was not related to surgical complexity, reoperation, or diagnostic class, but was related to significant life stress and coping style. Families that indicated a higher level of maternal education were more likely to utilise an adaptive style of coping. However those with a lower level of maternal education were more likely to utilise a less adaptive style of coping. Maternal education per se did not influence family function or family burden however coping style did. Family burden was greater for those that required reoperation and had a greater surgical complexity and significant life stress.
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ItemA pilot study to test a novel, nurse-led intervention to enhance the general health status of survivors of Hodgkin lymphoma attending a multidisciplinary, haematology late effects clinic( 2013)Background: The increasing numbers of Hodgkin Lymphoma (HL) survivors has raised awareness of the need to optimise long-term health outcomes and quality of life for this group of people. Objective: To develop and pilot-test the feasibility and potential of a nurse-led survivorship intervention to enhance survivors of HL awareness of health risks and adoption of healthy lifestyle behaviours. Methods: A pre-test, post-test design was used. Thirty survivor participants and 30 healthy controls were recruited to the study. Data were collected using the General Health Index and the Health Promoting Lifestyle Profile II at four time points. The intervention included: i) exploration of knowledge of health risks and lifestyle behaviours; ii) delivery of a tailored education package; iii) screening for unmet supportive care needs and iv) development and delivery of a tailored survivorship care plan. Results: Despite length of time since end of treatment a considerable profile of unmet need was identified. More than half of the survivor participants (57%) reported some level of fatigue for most of the time in the last two weeks; 47% reported feeling a lot of worry; 37% reported sleep problems; and 23% reported feeling depressed. Statistically significant improvements were seen for several domains. These included: physical activity (p=0.014); nutrition (p=0.0005); stress management (p=0.002) and health promoting lifestyle (p=0.005) from baseline to 6 months. No additional resources were required to provide the intervention as all aspects were delivered within existing resources of the haematology late effects clinic. Conclusion: The nurse-led intervention was shown to be feasible and demonstrated significant potential to improve awareness of health status and healthy lifestyle behaviours among survivors of HL. A randomised controlled trial is now needed to further test the efficacy of the intervention; determine optimal dose and the best time to deliver the intervention to prevent the levels of physical and emotional need reported by this study group, being reported by survivors of HL in the future.
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ItemWarfarin therapy in infants and children( 2004)Much of the evidence that guides anticoagulant management in infants and children has been presumptively extrapolated from adult medicine. We now know that there are several reasons as to why such extrapolation may not be ideal. This study sought to explore key outcomes of warfarin management in infants and children. The medical literature supports a direct association between patient knowledge and the stability of warfarin therapy. Phases One and Two of this project respectively investigated Parental and Nursing staff understanding of warfarin therapy in the paediatric population. Phase Three constituted a retrospective audit of warfarin management at a single tertiary paediatric centre over a two-year period. Data collected aimed to shed light upon the efficacy and safety outcomes of warfarin therapy in this cohort. Phase Four consisted of the development and implementation of a novel parent education program, which was piloted in a trial of home monitoring of warfarin therapy. Results of Phases One and Two demonstrated that parental and nursing understanding of warfarin therapy in children is poor. Although a causative link cannot be proven between the level of knowledge each of these cohorts possess, the role nurses play as educators must be reviewed in light of these outcomes. Phase Four demonstrated that parental understanding of warfarin therapy significantly improved following implementation of a novel education program, and these improved knowledge outcomes can be sustained over time. This program facilitated the implementation and evaluation of a home INR monitoring pilot study. Target therapeutic range (INR) achievement compared favourably with studies reported in adult patients, despite the presence of numerous confounding factors in the paediatric population. However, adverse event rates were higher than has previously been reported for similar paediatric populations. The incidence of adverse events appeared to be greater in patients not managed by a dedicated anticoagulant clinic. Warfarin management in children presents unique challenges that must be addressed if optimal anticoagulant therapy is to be achieved.
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ItemMental health nurses’ decision making for people presenting to the emergency department with deliberate self-harm( 2012)BACKGROUND: The management of deliberate self-harm presentations in Australia has increasingly become the responsibility of the hospital Emergency Department (ED). Assessment in Victoria is primarily the responsibility of mental health nurses who are based in the hospital EDs. They assess the presentation and implement appropriate disposition of these patients. The dispositional outcome depends on an assessment of the risks associated with the presentation and the principles of managing the patient in the least restrictive environment. In most cases the dispositional outcome and subsequent treatment is unremarkable and successful. When there is a suicide, there has been a tendency in the media to at times apportion blame to the clinicians for failing to prevent the patient killing themselves. The underlying assumption is that there is a “gold standard” and that clinicians should agree on dispositions for similar types of presentations. This assumption is not supported by research. The proposition that there is agreement in dispositional decision making throughout the industry is not examined in existing research. It is this gap that the present study sets out to explore. AIMS: 1. To investigate variations in patient disposition decisions, following deliberate self-harm risk assessment by Australian mental health nurses. 2. To explore the demographic factors of clinicians that may affect dispositional decision making for deliberate self-harm risk assessment. 3. To explore the clinician’s reasoning processes, leading to their dispositional decision making. CONCEPTUAL MODEL: A conceptual model of the safety and risk factors related to deliberate self harm presentations was developed and was informed by a literature review. This model was based on the demographic characteristics of the patient, level of social connectedness and intellectual functioning. This differed from the widely accepted model that utilises diagnostic categories and demographics. From this model a series of vignettes was developed. Two vignettes were designed to test the model (one that had very high safety factors and one with very low safety factors). A further seven cases were constructed with varying levels of perceived risk and safety. These vignettes were distributed to experts in the field to test for content validity and were found to be representative of typical deliberate self-harm presentations to EDs. METHODS: A cross sectional survey was administered to mental health nurses who were members of the Australian College of Mental Health Nurses. Questions were asked about the demographics of the participant along with a series of questions about the vignettes. Participants were asked about their perceptions of the deliberate self-harm intent of the subject and the disposition that the participant believed was appropriate for that vignette. For each of the questions, reasons for the decision were sought. RESULTS: The survey achieved 210 completed responses 56 of these were from the conference. Outcome was based on agreement and explanation. The quantitative results showed a significant agreement on deliberate self-harm intent across all but one of the vignettes by participants. The two test vignettes achieved agreement on disposition giving confidence in the model. The remaining seven vignettes, designed to balance safety and risk factors, showed poor levels of agreement for disposition. No demographic data consistently explained this variation. In the qualitative analysis the reasons given for dispositional decision in some cases were as conflicted as the decisions themselves. Often the same justification was given for treatment in the community and for a decision to hospitalise. CONCLUSION: Agreement was reached across clinicians on the assessment of deliberate self-harm intent. Only in one vignette was the null point included in the confidence intervals. There was a lack of agreement as to appropriate disposition between clinicians. This finding indicates a high level of subjectivity in dispositional decision making and suggests that for the same presentation different clinicians would make different dispositional decisions. The current work has highlighted individual differences between clinicians assessing in isolation, further research is indicated to investigate the effect of team dynamics on decision making. The findings of such research may prove useful as a tool for testing the formative and normative functions of peer supervision within a team environment. This may help understand the dynamics of decision making within the team and assist that team work towards understanding the dynamics at work in dispositional decision making.
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ItemQuality of life assessment in children requiring oral anticoagulant therapy( 2011)The absence of robust evidence regarding the management and clinical outcomes of anticoagulant therapy in children challenges interpretation of the risks and benefits of long-term anticoagulation therapy for children. Decisions about treatment increase in complexity in light of the potential burden of treatment on children and families. Quality of life (QoL) is a recognised and validated measure of the burden of treatments for children; yet, there is a lack of data about the impact of long-term warfarin therapy on QoL for children and families. This thesis describes the first study to evaluate the impact of a home international normalised ratio (INR) self-testing (home ST) program on the QoL of children and their families. The aim of the study was to determine if participation in a home ST program improves QoL for children requiring long-term warfarin therapy and their families. Parents of children requiring long-term warfarin therapy and children aged eight to 18 years participated in the QoL study. Three validated QoL questionnaires, the Pediatric Quality of life Inventory Generic Core Scale™, the Pediatric Quality of Life Family Impact Module™ and the KIDCLOT Pediatric Anticoagulation Quality of Life © inventory were employed to measure QoL. Questionnaires were completed before commencing home ST and six to 12 months later. Participants answered four open-ended questions when completing the questionnaires for the second time. Fifty-six families entered the home ST program during the study period. The children were aged between 2 and 17 years. Fifty-five parents and 35 children completed QoL questionnaires. Results of INRs tested at home were collected. The percentage of time the children’s INRs were in their target therapeutic range was 71.3%, which is comparable to many published paediatric studies of home ST. Parents reported statistically significant improvements in QoL for themselves, their family and their child, across all questionnaires following the commencement of home ST (mean difference in score p ≤ 0.003 on all questionnaires). The children’s scores of their own QoL also improved; however, this improvement was not significant. Parents’ report of their children’s QoL was significantly lower than the children’s report of QoL on all questionnaires at both time points. As well as being the first validated baseline QoL data in an Australian population of children requiring oral anticoagulant therapy, this study reports QoL for the largest cohort of children requiring warfarin therapy worldwide. The employment of both quantitative and qualitative methods to assess QoL enhanced understanding about the impact of home ST on QoL. This study has demonstrated that home ST in a population of children requiring long-term warfarin therapy is safe, efficacious and improves the QoL of children and parents. This study confirms home ST successfully reduced the burden of therapy and maintained excellent clinical outcomes. The results of this study not only identify the impact of warfarin therapy upon QoL in children, but offer an alternative evaluation strategy to sensitively measure the impact of interventions in this population. Accurate QoL assessments ensure children’s and families’ values are integrated with the current evidence for best clinical practice.